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Healthcare Reform Means Big Changes for My Private Practice


Not only will medical practices see the addition of newly insured patients to be cared for, but we will also see changes for established patients.

As we draw toward the close of 2011, the upcoming changes to be enacted for last year's passage of the Affordable Care Act are already changing the dynamics of my private practice. Not only will medical practices see the addition of newly insured patients to be cared for, but we will also see changes for the established patients that we already are caring for. Such an example can be seen with our patients enrolled with Virginia Medicaid.

My office manager attended a meeting just this week that detailed such changes for our Medicaid patients. At present, patients who are beneficiaries of Virginia Medicaid have a single payer with a single formulary of medications and a uniform set of rules to follow for claims submissions and processing of payments. We have recently learned that Virginia Medicaid will be contracting with not one, but six separate payers for the provision of services to its current beneficiaries.

This change will be difficult for my current practice to digest and process. Now we are faced with being credentialed with not one, but six separate contractors. Now we will have not one, but six separate formularies to search. Medicaid patients will be asked to select one of six contractors to participate with and they must then select a physician or practice credentialed with their specific contractor. The process for making referrals and ordering procedures has now increased in complexity by a factor of six. To make this even more complicated, we all know that Medicaid patients are not traditionally very timely in planning for the future and getting them to even respond to correspondence by mail will be very difficult to say the least.

Unfortunately, the reimbursement for services provided to Medicaid patients is already very low compared to traditional fee for service Medicare and private insurance. This low reimbursement schedule already forces private practices like mine to be very mindful of the percentage of Medicaid patients enrolled so that the overall percentage is not so large that it affects the vitality of our practice. I am concerned that this new provision will make it more difficult now for Medicaid patients to receive the medical care that they need.

My practice will now have the difficult task of deciding whether or not to accept new Medicaid patients based upon the new provision of services rule. It will make it even more difficult to seek reimbursements for services provided to patients of other physicians that I provide cross coverage for on the weekends for hospital call. If our practice chooses to participate with only one or a select few Medicaid contractors, will we still be able to provide care for other patients that we are not participating with their contractor? How are we to handle this process? The answer to this question has unfortunately not been provided to us as of yet, and to make matters worse, the Medicaid patients are going to be asked to choose a plan before the end of this calendar year.

This is only but one example of how healthcare reform will be impacting my current practice. I am fearful that this is only just the beginning as we continue to wade into the waters of healthcare reform and see how the upcoming legislation will change the way we provide care to our existing patients.

To make the process even more complicated, the discussion of reforming the SGR formula is still in debate and this will most certainly dictate reimbursements from not only Medicare and Medicaid, but for other third-party payers as well. It will be very interesting to say the least to actually see how the upcoming changes impact the current workflow and traditional day-to-day practice for medical offices nationwide. At present, I will remain a private practice physician because the pros of private practice for me greatly outweigh the cons. Even more interesting will be the upcoming debates and the Supreme Court hearings regarding the constitutionality of healthcare reform and whether or not the upcoming elections of 2012 will provide for the possibility to repeal the law as we see it currently.

Learn more about J. Scott Litton, Jr., MD, and our other contributing bloggers here.


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